If you rent can you provide you landlords name and contact information? If so, please do so below.

Yes

No

Landlords contact information:

Are you currently receiving any VA benefits? *

Yes

No

Do you have any health issues that you would like to have a confidential conversation with our application evaluators about? *

Health concerns will not prevent you from getting a dog from us, however we need to be aware of any issues that might be a factor in helping us choose the proper dog for you.

Yes, please contact me to discuss my condition

No, I do not have any health issues to discuss

Can you provide a letter from a health care provider stating you require or would benefit from a service animal? *

Yes

No

Have you ever considered hurting yourself or others? *

Are you currently in any form of counseling? If yes, how often and where do you attend? *

Are you currently employed? *

Yes

No

If so, how many hours per week do you work?

Will you require your PTSD Service Dog to accompany you to work? *

Yes, always

Yes, occasionally

No, never

How social are you? *

Very, I leave the house 5 + days/week

Somewhat, I leave the house 3-4 days/week

A little, I levae the house 1-2 days/week

Not very

How often do you exercise? *

Regularly, 5+ times/week

Often, 3-4 times/week

Somewhat often, 1-2 times/week

Not very often

Do you currently have any other animals living in your home? *

Yes

No

If Yes, how many? *

1

2

3+

Not Applicable

Are they current on their vaccinations?

Yes

No

Not Applicable

Are you applying for an Emotional Support Dog or PTSD Service Dog? *

Emotional Support Dog

PTSD Service Dog

Have you ever applied before for an Emotional Support or PTSD Service Dog? *

Yes

No

If so, where?

What size dog are you looking for? *

Are you willing to commit to attending 6 months of dog training classes (one class per week)? *

Yes

No

What are five things you need your new companion to do for you? *

Do you believe your current situation will allow you to keep a service dog for at least 8-10 years? *

Yes

No

Will your service dog spend most of its time with you both at home and outside of the home (and not confined alone/by itself). *

Yes

No

Do you understand that a service dog is not a family pet and has been trained for specific jobs to perform for you and should therefore interact mainly with you? *

Yes

No

Do you acknowledge that by taking one of our service dogs, you are a representative for Operation At Ease and the service dog industry and will be expected to maintain both your dogs training skills and your skills as an owner/handler? *

Yes

No

Do you agree that your service dog will not be off its leash except in a secure area? *

Yes

No

Do you agree that you will take full responsibility for the care of your service dog as far as their safety, health & welfare? And if you are not able to take full responsibility for these things, a qualified person will do it for you? *

Yes

No

Will you or a qualified person feed your service dog a good quality dog food twice a day and maintain its ideal weight? *

Yes

No

Will you or a qualified person ensure your service dog gets daily exercise? *

Yes

No

Will you or a qualified person take full responsibility for cleaning up after your dog in public places? *

Yes

No

Do we have your permission to contact anyone who is listed on this application if we need further information? *

Yes

No

When are you available to attend classes? *

Afternoon

Evening

Either, I am available both afternoons and evenings

List three personal references we can contact, Name Relationship Phone Number *

I _____________________________(print name) have answered all sections honestly and to the best of my ability.

I understand that, if I do not complete this program in it's entirety, my dog will not be designated as an Operation at Ease, Inc. trained service dog. It will be considered my pet and will remain in my care. *

By checking this box I certify that I fully understand and agree to these terms.

Signature (Print this form with completed answers and we will have you sign below in person):

A copy of your DD-214 must be submitted before your application can be processed. We will accept either a PDF version via email or a photocopy via postal service mail. Our email and mailing address can be found here.